Healthcare Provider Details

I. General information

NPI: 1609339555
Provider Name (Legal Business Name): RAVI GAURANG SHAH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 W PARK AVE BLDG C
OCEAN TOWNSHIP NJ
07712
US

IV. Provider business mailing address

804 W PARK AVE BLDG C
OCEAN TOWNSHIP NJ
07712
US

V. Phone/Fax

Practice location:
  • Phone: 732-466-3966
  • Fax:
Mailing address:
  • Phone: 732-466-3966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02759500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: